A pregnancy will normally last for 40 weeks. Pre-term birth is used to describe the ‘early birth’ of a baby before 37 weeks of pregnancy. Around 60,000 babies are born prematurely in the UK each year, which is around 1 in 13 live births.

The care of premature babies has advanced rapidly in recent years. Babies born prematurely today have a greater chance of surviving without complications but some can develop more serious problems, which in part is related to how early they are born. The level of ‘viability’ is considered to be around 23 weeks, meaning that babies born older than 23-24 weeks can be treated to help them survive.

Complications of preterm birth can include:

Breathing difficulties

Problems maintaining temperature

Feeding difficulties

Disability or developmental problems

 Causes and risk factors

The exact causes of preterm labour are not fully understood. Sometimes there may be an identifiable reason, but this is not always the case. Any pregnant woman is at risk of having a pre-term birth, but there are certain risk factors that increase the chance.

 Causes and risk factors:

• Multiple pregnancies - twins triplets etc.
• Prolonged rupture of membranes- the protective fluid sack around the baby ruptures.
• Bleeding in pregnancy.
• Infection.
• Problems with the cervix or structural womb abnormalities.
• Previous premature delivery.
• Elective preterm birth - early delivery is needed for a medical reason (Pre-eclampsia or growth restriction).

Certain lifestyle factors can also increase the risks:

• Smoking.
• High alcohol intake.
• Illegal drug use.
• Social problems.

Symptoms

Symptoms can vary depending on the possible cause of the pre-term labour. Most women get some warning symptoms, but some do not. It is important to attend routine antenatal appointments so that potential problems can be identified. 

Symptoms can include:

• Pain in the abdomen similar to normal labour - this may be constant or in ‘waves’.
• Back ache.
• Vaginal bleeding.
• Vaginal discharge that is watery or smelly.
• Possible urine infection and pain when passing urine.

The symptoms may not always be obvious, so if anything does not feel right always ask for advice from a doctor or midwife.

Diagnosis

If any symptoms occur then the midwife or doctor will assess the severity and a hospital assessment may be needed. Having these symptoms does not always lead to a pre-term labour. Early management of potential problems such as treatment for urinary or vaginal infections may help to prevent it happening.

Pre-term labour is diagnosed by the opening of the cervix (neck of the womb) and the presence of contractions before 37 weeks of pregnancy.

Test that may be done:

• Assessment by a doctor
• Observations of temperature, pulse, blood pressure
• Monitoring of contractions.
• Assessment of the baby including a scan and monitoring the heart rate.
• Internal examination to check the cervix.
• Blood screening and vaginal swabs to detect infection.
• Tests in certain circumstances may be able to predict the chance of early labour.

Treatment

Treatment will depend on many factors. The aim of treatment is to allow the baby to continue inside the womb for as long as possible. However, the baby may have to be delivered early if the baby is distressed or if there is worrying infection or heavy bleeding. In some cases if labour has progressed too far or other problems exist it may not be possible or safe to try and stop early labour.

If premature labour is suspected steroids may be given to the mother by injection. This helps the baby’s lungs develop and prepares them for early birth.

Treatments that can be given to the mother to try and prevent labour:

• Antibiotics
• Drugs to stop contractions
• Cervical stitch or suture to hold the cervix shut- this can only be used in certain circumstances.

Treatment options for premature babies:

Treatment depends of the health of the baby and how early it is born. Babies born between 34-36 weeks normally need help with maintaining temperature and feeding. In many cases this may not require care on a neonatal intensive care unit and these babies can be looked after on a specialist ward. Babies born earlier than 34 weeks will almost certainly need help with breathing and will require care on an intensive care unit.

Treatment can include:

Care in an incubator or warm cot to help maintain temperature.

Breathing support by either a ventilator or continuous positive airway pressure system

Administration of surfactant to help with breathing.

Drips to provide food, fluid and medicines.

Help with feeding.

Antibiotic treatment.

Blood tests or transfusions.

Scans, surgery or other medical interventions.

It can be very daunting for parents whose baby is born early, especially if intensive treatment is required. A long stay in neonatal intensive care unit may be needed and complications can develop over time. However, staff are highly skilled and trained to help parents in this situation. Asking questions, being as involved as possible with baby care and making contact with other parents in a similar situation is encouraged and may help.

Do not be afraid to ask for help and support, from friends, midwives, doctors and family.

 Prevention

The risk of pre-term birth can never be fully eliminated but certain things may reduce it. In particular, it is important to explain any previous history of preterm birth and pre-existing medical conditions to your midwife so that appropriate care and monitoring in the pregnancy can be planned.

Other actions include:

• Attending all routine appointments.
• Reporting any symptoms or problems early on.
• Maintaining a healthy diet and lifestyle.
• Avoid smoking, using drugs or drinking alcohol.

Pre-term Birth: Text Version.

Hello and welcome to our podcast.

 Today we will be speaking about pre-term birth with Professor Donald Peebles who is Head of the Research Department of Obstetrics at UCL (University College London) and a consultant obstetrician.

More research is needed into pre-term birth. 1 in 13 babies are born prematurely in the UK and premature birth is responsible for most neonatal deaths and long term problems. Survival rates have greatly improved but the number of babies being born prematurely has not decreased.

 Hello Donald thanks for joining us. One your specialist research areas is premature labour and it’s great to have your expert opinion on this.

 Could you first help us to understand what is pre-term birth?

 Most women have their babies after 37 weeks of pregnancy and pre-term birth is when you have a baby before that. The time that we are really worried about is when women have their babies very prematurely which could be more than 3 months before 40 completed weeks of pregnancy.

 Could you tell us a little bit more about what are the short and long term effects it can have on babies?

 So, pre-term birth is a problem much more for the baby than it is for the mum and the reason that we are so concerned about babies who deliver very early is that they are more likely to die immediately after birth. That is because by and large their organ systems haven’t had time to develop properly and they are not fully mature. So for instance their lungs aren’t fully adapted for breathing air until about 35 or 36 weeks of pregnancy.  Babies born 3 months early may need to have help with breathing, supplementary oxygen, ventilation and can go on and have long term complications with their lungs like asthma or respiratory difficulties. The other main organs that have not developed and can cause problems are the brain. Babies born prematurely are more likely to have long-term problems with brain development like a slightly lower IQ and also the intestines aren’t fully developed for coping with things like maternal breast milk; so one has to very carefully introduce feeding by mouth in these very premature babies.

 We don't always know why women go into labour early. Could you explain a little bit more about the causes and risk factors for premature labour?

 It remains something of a mystery and that is why we are so keen on doing research. Why what is a normal process at 40 weeks of pregnancy (women going into labour) should occur out of the blue in some women as early as 23 or 24 weeks of pregnancy. We do know that there are some things that make you more at risk of having a baby prematurely; if you have had a preterm baby before then that would increase the risk slightly of it happening again, we know that if you have multiple pregnancies like twins or triplets that can increase the risk of having a baby prematurely and we also know that people who have had surgery on the neck of the womb (the cervix) are slightly more at risk of having pre-term births. So we know that there are some associations but still the majority of pre-term births occur in women with very few risk factors.

 Are there any symptoms or warning signs that women should be aware of/ watch out for?

 The most common presentation is people actually feeling or experiencing the symptoms of labour; so they are the same symptoms that you would experience when you went into labour normally at 40 weeks but you experience them at say 24 weeks of pregnancy. So that would be things like rupturing the membranes- water coming out vaginally, having painful contractions which are quite regular or sometimes of bleeding. Occasionally, particularly if the cervix doesn’t work very well, there can be very few symptoms. The cervix can open up really quite quietly without causing much in the way of discomfort and women notice increase in vaginal discharge, a feeling of discomfort and they might choose to go in and be checked over, and at that stage it could be seen that the cervix has actually opened up quite substantially.

 Can you take us through the types of treatment that women might expect to have discussed with them? So as you were saying before, it does depend on the circumstances if membranes have ruptured or if they haven’t….

 At the moment the risk of pre-term birth will only become apparent when people actually present with early signs of preterm labour. Now the encouraging thing is that even if you have contractions quite frequently, the majority of women who present like that actually aren’t in pre-term labour and if you do nothing the contractions will just settle down and go away; but what we try and do as midwives and doctors is to focus our treatments and care on those who are actually going to go into pre-term labour.  The management at the moment would be to try and temporarily stop the contractions using drugs which relax the muscles of the womb. That only postpones the pre-term birth, but that is important because it means that we can give the mother two injections of steroids which cross the placenta and they mature the baby’s lungs and brain and so improve some of those complications that I talked about earlier. The other thing that we can do is we can use that 24 or 48 hours to ensure that the mum actually delivers the baby in a hospital which has specialist facilities for optimizing the care of these very pre-term babies.

 I understand you are supervising one of the studies Wellbeing of Women are funding about the role of the immune system of the cervix in preventing pre-term birth. Can you tell us a little bit more about that?

 One of the things that we really need to do with research is to identify women who might have a pre-term baby, before they actually go into pre-term birth. This is because by the time they go into pre-term birth the number of treatment options are very limited and it is very difficult to prevent. So we are interested in looking at factors that you might be able to study early in pregnancy which mean women are at an increased risk and one of the things that we are focusing on is the cervix (the neck of the womb). The reason that we are interested in the cervix is because we know that in all women the vagina, like the mouth, is full of bacteria and we know that in most women by the time they get to the end of pregnancy, the inside of the womb is a sterile cavity so there are no bacteria. But what we also know is that women who have pre-term babies, by the time they go into pre-term labour often the womb has bacteria inside it. So we think that one of the reasons that might happen is that the cervix which acts as a barrier between the vagina in the inside of the womb perhaps doesn’t function properly to keep bacteria out. We can study the cervix early in pregnancy both by using ultrasound to measure how long it is and therefore how effective a barrier it is and we can also take swabs from the cervix to look at proteins which are made by the cells lining the cervix, which might kill bacteria and stop them getting into the womb. Our speculation is that women who have poor cervical function for whatever reason might be at an increased risk of pre-term birth. If that were the case then we are also looking at ways of intervening to improve the function of the cervix to try and reduce the risk of prematurity.

 So if that was proven possibly, you would be able to identify women at risk and look at treatments…

 Yes, as I said if somebody comes in, in pre-term labour that is probably the end result of a very long sequence of events involving hormones and proteins in the uterus which put somebody into labour. To prevent that from happening you have to get in at the beginning of that sequence of events and so we think that early treatment and prevention is the only way of doing that and that might be as early as 12 weeks of pregnancy. The idea would be that at 12 weeks we look at the cervix and assess its function and then we say somebody is at risk. Is there a treatment that we can give them then to prevent pre-term labour?

 So preventative and looking at from really early on the cause…

 Exactly, yes.

 Is there anything women can do themselves to reduce their risk?

 There aren’t any specific interventions that have been found to improve the risk of preterm birth. There is no doubt that all pregnancy complications are reduced in people who go into pregnancy in a healthy state. So for instance there is an association between bad tooth care and pre-term labour. As part of preparation for pregnancy, having a very good diet, stopping smoking or drinking much and having your teeth put in good order, they are all very good things.

 And also making sure if you have any concerns or worries that you voice these and get these things checked out early, rather than leaving something that you are concerned about…

 That’s absolutely true. For most women the risk of pre-term labour would be very small but certainly for women who have had a previous pre-term baby then pregnancy represents an extremely anxious making time.

 Apart from the research that you are currently involved in, is there any other area of this topic that you feel there is a great need for further research?

 One of the difficulties with research in this area is that it’s important to be clear what is the most important outcome from the research. For pregnancy doctors (obstetricans) the most important outcome in the past has thought to be when the mother actually delivers. So all treatments have been designed to make delivery later and the assumption has been that that leads to an improvement in the outcome of the baby. More recently it has become clear that the outcome that really matters for women is how their baby does. So it’s the long term outcome of the baby which is really the important thing and it’s become clear that just delaying an inevitable delivery doesn’t necessarily improve the outcome of the baby.  I think one of the most important things for future research is to follow babies up after pre-term birth or after any treatment to prevent it, to make sure that in 5 or 10 tears time those babies actually do better as a result.

 Is there anything else that you would like to add to the subject that we haven’t discussed?

 There are other exciting areas of research that have been carried out in this country. There is a ramdomised control trial currently ongoing, looking at progesterone which is a hormone that is naturally made which is thought to be responsible for keeping the baby in the womb until the right time. So the trial is looking at that whether giving women progesterone can actually prevent pre-term birth. That’s another exciting area of research.

 Thanks very much for joining us today it’s great to have your expert opinion.

 It’s a pleasure.

Find out the answers to common myths surrounding pre-term birth.

It is my fault that my baby has been born early

Pre-term labour is extremely unlikely to be your fault. There may be a variety of factors beyond your control which may have contributed such as, infection, illness, or an existing problem. If you ever experience these feelings is it important to talk about it and work through it. Speak to your doctor, midwife, neonatal nurse or support worker who will be able to offer support and further assistance if needed.

There is nothing I can do to prevent it

Often women go into pre-term labour without any risk factors. However, there are certain things that can be done to reduce the risk. Attend all routine appointments, report any symptoms or problems early on, maintain a healthy diet and lifestyle and avoid smoking, using drugs or drinking alcohol.

Spicy foods cause you to go into labour early

This is not true. Food poisoning and infection can cause premature labour but spicy food alone does not.

Having sex causes premature labour

Sex alone does not cause preterm labour. However, if you have a known risk of preterm labour or any other problems then doctors may advise avoiding sex during the pregnancy.

To find out about our research follow these links:
 

• The role of the immune system of the cervix in preventing preterm birth

• Baby Bio Bank

• New tests to predict the onset of labour in women

• New drugs approaches to prevention of preterm birth

• NHS Choices website also has a range of health information. This can be found at: http://www.nhs.uk/Pages/HomePage.aspx